Understanding the gender gap in advanced practice nursing: A qualitative study

Abstract Aims We aim to explore the perceptions of registered nurses undergoing the advanced practice nurse preparatory programme and of advanced practice nurses towards the recruitment of men into the advanced practice nursing workforce. Background Given the need to expand and diversify the advanced practice nursing workforce, it is important to recognize the potential implications of gender disparity. It is critical to understand why few males are recruited into the advanced practice nursing preparatory programme and to determine whether gender‐related bias is present in the professional development of nurses. Method We use a descriptive qualitative design. Semi‐structured interviews were conducted via Zoom (April to August 2021). Results Three themes were generated: ‘The odds are eventually in the favour of men’, ‘The APN career‐track is unpopular among men’, and ‘Balancing the gender gap in the APN workforce’. All themes are supported by three subthemes. Conclusions Although males in nursing enjoy opportunistic advantages in entering the advanced practice nursing workforce, they are not interested in the role and not staying long enough in the nursing profession to become advanced practice nurses. Implications for Nursing Management Nurse managers should be more cognizant of the different social stereotypes faced by males and females in nursing. With such awareness, they can be more supportive and less biased in career counselling and job appraisals.

a global shortfall of 9 million nurses to meet population health needs by 2030.
In Singapore, gender disparity has persisted. Although the number of male nurses has risen with time, the pace is not encouraging: their proportion among registered nurses (RNs) has only increased from 8.2% in 2008 to 11.6% in 2020 (Singapore Nursing Board, 2021). The phenomenon is also true among Singapore's advanced practice nurses (APNs), who are nursing leaders spearheading patient care with demonstrable clinical contributions (Laurant et al., 2018;Smits et al., 2020;Woo et al., 2017). The proportion of males among APNs remains disproportionately low: they currently account for less than 5% of the APN workforce (Singapore Nursing Board, 2021).

| Men in nursing
Nursing being a female-dominated profession has precipitated men in nursing to experience gender role conflicts, stereotypes, and challenges in educational and clinical settings (Younas et al., 2019;Zeb et al., 2020). Men in nursing started encountering such negative experiences while they were students. One common assumption held by many is that men who end up pursuing nursing are only doing so because they are not bright enough to become doctors (Brody et al., 2017). Often, they are also questioned about their sexual orientation (Brody et al., 2017). As a result, male nursing students reportedly have concerns and uncertainties about becoming a nurse. They fear poor acceptance of male nurses among healthcare colleagues and patients would negatively impact their career prospects (Younas et al., 2019;Zeb et al., 2020).
Stereotypes about masculinity have influenced nursing care assignments in clinical practice. Men in nursing are expected to work in fast-paced clinical environments, such as intensive care units or emergency departments, where there is more heavy lifting (Cheng et al., 2018). Men are also thought to be better suited for psychiatry settings where their physical strength would be helpful in managing patients who are at risk to themselves and others (Jordal & Heggen, 2015). In some contexts, men are outrightly precluded from caring for female patients (Zeb et al., 2020). These role expectations can marginalize and cause a strain among men in nursing (Smith et al., 2020).
To avoid gender role conflicts and discrimination, some men become nurse educators. Although these men received more respect and appreciation as educators, they still feel compelled to constantly prove their worth and improve themselves. These feelings stemmed from prejudices engrained in the nursing culture against male nurses (Zeb et al., 2020). Over time, these issues men face in nursing could culminate and result in feelings of isolation, stress, and burnout (Carnevale & Priode, 2018). These could negatively impact retaining men in nursing (Rajacich et al., 2013).

| Recruitment of APNs in Singapore
In Singapore, APNs are Masters-prepared nurses with a professional licence to practice beyond an RN's fundamental scope of practice.
The role of an APN in the context of Singapore represents a hybrid between that of a nurse practitioner and a clinical nurse specialist (Woo et al., 2019). Additionally, some APNs have collaborative prescribing authority (Ministry of Health, 2018).
Currently, the Singapore Nursing Board oversees the APN practice and licensure, the prerequisite for which is a formal preparatory training. This comprises an 18-month Master of Nursing programme at the National University of Singapore and a 12-month supervised internship under a provisional licence (Singapore Nursing Board, 2020). Upstream enrolment of RNs into the Master of Nursing programme requires endorsement and recommendation from their nursing leaders (besides minimum academic requirements and clinical experiences) (National University of Singapore, n.d.). An aspect unique to Singapore is that such matriculated RNs will enter an employment bond with their healthcare institutions, under which they are thus expected to develop their careers as APNs. Accordingly, nursing leaders are crucially involved in selecting RNs for APN practice (Woo et al., 2020).
A robust nursing workforce is critical to attaining universal health.
Thus, there has been an ongoing interest to recruit more APNs to strengthen the APN workforce, as demonstrated by the aim of Singapore's Ministry of Health to double the number of APNs by 2030 (Begum, 2021). Accordingly, expanding the APN workforce entails addressing the gender disparity, especially given the evolving healthcare and sociocultural landscape (Thompson et al., 2020). Moreover, diversifying the APN workforce translates into the practical utility of tapping into the male population for their expertise. This builds a more gender-inclusive environment for males and ultimately improves patient care and experiences (Smith et al., 2020).
Given the need to expand and diversify the APN workforce, it is important to recognize the potential implications of gender disparity. Therefore, it is critical not only to understand why few males are recruited into the APN preparatory programme but also to determine whether gender-related bias is present in the professional development of RNs. Furthermore, it may be propitious to understand if men are staying long enough in nursing to become APNs. Such findings are envisioned to provide practical insights into potential solutions to address gender disparity.

| Aims
Accordingly, this inquiry aimed to explore the perceptions of RNs undergoing the APN preparatory programme and of APNs towards: i. the shortage of men in the APN workforce; ii. the selection and recruitment of men into the APN preparatory programme; and iii. the influence of having more men in the APN workforce on the professional image of nursing in Singapore.

| Study design
A descriptive qualitative design (Polit & Beck, 2012) was adopted. Participant recruitment, data collection, and data analysis were iteratively performed to explore diversity from the nurses' perspectives. Additionally, this study adhered to the 32-item Consolidated criteria for Reporting Qualitative research (Tong et al., 2007) (Appendix S1).

| Setting and sample
Singapore, a city-state with a total population of 5.45 million people and a population density of 7485 people per square kilometre, was the study setting (Singapore Department of Statistics, 2022). There are 35,948 RNs (32,621 in active practice) and 330 APNs (327 in active practice) in Singapore (Singapore Department of Statistics, 2022).
The participants were purposively sampled. Included in this study were consenting male and female registered APNs, APN interns, and Master of Nursing students aged 21 years and above. Within the context of this study, the term 'APNs' refers to nurses who have completed all aspects of the formal APN preparatory training. 'APN interns' refers to Master of Nursing graduates in the midst of their 12-month supervised internship under a provisional licence. Finally, 'Master of Nursing students' refers to RNs receiving formal APN education at the university. Participants must have access to a personal computer or mobile device with microphone and camera functions.
APNs, APN interns, or Master of Nursing students who refused to have their interviews audio-recorded or their web cameras turned on during the videoconference were excluded.
Electronic invitation letters with information about the study were disseminated via email to all the National University of Singapore Master of Nursing alumni by the programme administrator.
In addition, interested alumni were requested to contact the study team via email. The study team would then respond and arrange a mutually convenient time to go through the consent process and conduct the interview. Snowballing sampling was also adopted. The study team also received referrals from the study participants.

| Data collection
Each consenting participant then took part in a single session, individual, semi-structured interview through videoconferencing (Zoom) between April and August 2021 with one of the authors (B. W., Female, PhD-prepared). During the interviews, web cameras and microphones were set up so that the researcher and participants could see and hear each other (including the participants' non-verbal cues). The researcher had no prior relationships with the participants.
With a flexible interview guide, the researcher explored the participants' perspectives towards males in the APN workforce. Examples of the questions were: 'Why is there an under-representation of males in the APN workforce?' and 'Do you think nursing leaders take into consideration the gender of the RN when nominating him or her for the MN programme?'. The interviews were audio-recorded and transcribed in verbatim, ranging from 48 to 64 min (median = 54 min).

| Data analysis
Data analysis and data collection took place in parallel and complemented each other. During data analysis, no new information and codes were generated between the 15th and 16th interviews. It was then the study team agreed that data saturation was achieved (Green & Thorogood, 2004). Accordingly, recruitment concluded at the 16th interview. Following this, thematic analysis, guided by Braun and Clarke (2006), was undertaken inductively, with the themes and subthemes being extrapolated from the data rather than from existing conceptual frameworks or theories (Fereday & Muir-Cochrane, 2006).
When generating codes across the data corpus, some techniques from the grounded theory were used (Charmaz, 2014). The techniques included line-by-line coding of the interviews transcribed in verbatim, discussions among study team researchers about emergent codes and deviant cases, and adopting a constant comparative method (Strauss & Corbin, 1990). The researchers read the interview transcripts and listened to the audio-recordings repeatedly to gain familiarity with the data. Next, codes were refined and arranged into potential themes and subthemes using a semantic approach. The themes and subthemes were assessed if they cohere meaningfully with the codes and data corpus. Subsequently, the themes and subthemes were refined and defined (Braun & Clarke, 2006). The constant comparative method was undertaken in coding, developing, reviewing, and defining themes. The relationships between and within each theme were compared (Strauss & Corbin, 1990). Discussions continued until all the researchers (B. W., G. Y. S., and Z. W.) agreed on the final themes and subthemes (Braun & Clarke, 2006).

| Rigour
To ensure the rigour of our study, criteria for authenticity and trustworthiness were upheld (Guba & Lincoln, 2018). Authenticity was ensured by exercising fairness, demonstrated by assigning equal consideration and weight to every participant's insights (Guba & Lincoln, 2018). Trustworthiness involves credibility, dependability, confirmability, and transferability. Each interview lasted more than 30 min to ensure credibility, allowing prolonged engagement with the participant. Additionally, to enable triangulation, the data analysis was undertaken by three researchers (B. W., G. Y. S., and Z. W.). Furthermore, member-checking followed the interviews, involving four consenting participants with contrary perspectives: They were first presented with the preliminary themes, subthemes and participants' quotes. Then, they were requested to examine the representativeness of their views (Birt et al., 2016). To ensure dependability and confirmability, the interview transcripts were checked by researchers not involved in transcription. Throughout the data analysis, an audit trail was kept alongside field notes and reflexive annotations to record the researchers' tendencies and intents. Lastly, to permit readers to determine the transferability of this study, the participants' sociodemographic characteristics, verbatim quotes, and relevant contexts were provided for their appraisal.

| Demographic profile
Of the 16 participants recruited (eight males and eight females), the majority were Chinese (n = 13) and were married (n = 12). Their ages ranged from 29 to 43 years (median = 36 years), and their nursing experiences ranged from 6 to 20 years (median = 11 years) ( Table 1).
Six were Master of Nursing students, three were in the midst of their APN internships, and seven were APNs. All but two of them were working with adult patients.

| Thematic findings
Three themes were generated, each of which was, in turn, supported by three subthemes that further illustrated the participants' perspectives towards the selection and recruitment of males into the APN workforce (Table 2). 3.2.1 | Theme 1: The odds are eventually in the favour of men The participants shared that there was no gender preference in the selection and recruitment of APNs into the workforce. However, they opined that males might enjoy opportunistic advantages over females in the selection for the APN candidature.

Subtheme: Objectivity in the selection process
In general, there is a stipulated set of objective criteria for selecting nurses for the formal APN preparatory education. According to the participants, any nurse might express their interest in the APN track to their direct reporting officers (usually the nurse managers or nurse clinicians of their wards or clinics). Following this, the managers or clinicians would submit a nomination for the interested nurse. Some participants shared that their institutions made application forms available on the intranet for interested nurses. Others added that potential candidates in their institutions were to be assessed for  T A B L E 2 Themes and subthemes

Themes Subthemes Quotes
The odds are eventually in the favour of men Objectivity in the selection process 'I do not think nursing leaders will take into account the gender. I think they look more into GPAs, so like they will consider your education background, and you are your contributions to the organisation, and how well have you performed. You have to score A for 3 consecutive years for your work appraisal and your GPA must be 3. In sum, the selection and assessment of the candidates by the nursing leaders and administrators were reported by the participants to be independent of the candidates' gender.

Subtheme: Differing gender-specific role expectations in the family
According to the participants, during the selection interviews, the candidates were frequently asked questions related to their families and the need for help at home while they embarked on the APN prepara-

Subtheme: The inevitable 'glass escalator'
Because nursing was a female-dominated profession, males who joined nursing would tend to stand out and be more prominent than females, as shared by the participants: … they [men] also understand that they are more outstanding as males you know, so for example, just within a ward, there's probably going to be only two or three males … Whatever they do is being magnified, if they have a compliment, wow, everybody knows right?
[sic] (P5, Female, Student) Against such a background, the participants observed that males appeared to be recognized and appreciated more often than females for any given work of similar quality. Furthermore, the participants added that males' opinions appeared to carry more weight than females' in their work environments. Moreover, being the minority in the nursing workforce caused them to receive unintended advantages over females in career advancement. Such observations led to the participants' view that male nurses were on a 'glass escalator' and T A B L E 2 (Continued)

Themes Subthemes Quotes
Good role models and better articulation of the role '… seeing how our APN seniors work is an inspiration to us. We see how they are equipped with masters and being APN, they do more for our patients. was not mandatory for nurse managers, nurse clinicians, nurse educators, or nurse researchers to be Masters-holders. In sum, although these considerations would be common to both genders, males appeared to be more affected by this, because of expectations on them to provide for their families: … for guys, opportunity costs and salary are very important. They must support the family.

| Theme 3: Balancing the gender gap in the APN workforce
The participants did not find males' lack of interest in the APN career track concerning. Nonetheless, they did see value in disrupting the status quo of their low numbers in the APN workforce.
Subtheme: Male APNs are 'good-to-have' and not a 'must-have' The scarcity of males in the APN workforce was not perceived to be unsettling. During the discussion on recruiting males into the APN workforce, one participant commented that having more male APNs 'is not a must-have but more of a good-to-have' (P10, Much of the existing literature drew attention to the discrimination men experience, in the form of gender role conflicts and stereotypes, throughout their nursing career (Brody et al., 2017;Younas et al., 2019). Interestingly, in this study, although gender-based stigmatization of nursing is ascertained as a longstanding issue in Singapore, men in nursing did not seem to experience discrimination with regard to professional development. Instead, males in nursing appear to be beneficiaries of opportunistic advantages in professional development. Despite the objectivity in the selection of APN candidates, males are more likely to be identified as potential candidates for APN training than their female counterparts. This can be attributed to the dominant role of females in childbearing and caregiving (Holahan, 1994) and is true even among highly intelligent females with successful careers. A systematic review (Schlegler, 2022) on the professional state of gifted adults has reported that females would experience significant changes in their careers after the age of 35 years.
Females were observed either to transit from being gainfully employed before starting a family to becoming homemakers or to remain gainfully employed without much career aspiration. Moreover, gifted females have also been reported to be more likely than gifted males to face trade-off decisions where they had to choose between their career or family: ultimately, they would gravitate towards a career that made allowances for their family planning (Schlegler, 2022). Such literature validates the findings in this study, considering that most RNs start their APN preparatory training in their 30s (Woo et al., 2020).
The term 'glass escalator' first introduced by Williams (1992), describes the underlying advantage men enjoy in female-dominated professions that facilitates their career progression. The phenomenon of such a 'glass escalator' has been underscored in this study. According to a few earlier studies, men may feel different or out of place among their female nursing colleagues but often do not feel discriminated against (Smith et al., 2020;Zeb et al., 2020). Conversely, as the minority in nursing, males have been reported by the participants to be more prominent than their females, and their positive work performances are more likely to be noticed. Such findings are echoed in Asian (Zhang & Tu, 2020) and Western (Smith et al., 2020) nursing populations. Moreover, across cultures, males in nursing have been observed to receive greater recognition from their managers than females. These observations therefore, lead to their favourable positions for career advancements (Smith et al., 2020;Younas et al., 2022;Zhang & Tu, 2020).
To address the 'glass escalator' phenomenon, an obvious implication for the management of staff would be to slow it down strategically (Brandford & Brandford-Stevenson, 2021). However, this is superfluous in the context of APN recruitment of males in Singapore.
Elucidated in this study is males' disinterest in the APN role, as explained by the achievement-orientated traits of males such as decisiveness, aggressiveness, independence, and firmness (Heilman, 2001), which are found among males in nursing too. This, therefore, causes them to prefer managerial positions, for which the career progression is more certain, in their organizations.
Ironically, despite the apparent opportunistic advantages of males in nursing, the impact of gender-based stigmatization of nursing remains evident. This longstanding stigmatization makes it challenging for males to adapt to the female-dominated nursing culture, which compromises their delivery of patient care and ultimately reduces their job satisfaction (Finnegan, 2019;Younas et al., 2022). Such negative implications deter males from staying in the profession long enough to become APNs. Therefore, as demonstrated by our findings, addressing the gender gap within the APN workforce fosters a healthier and more inclusive working environment.
As elucidated in this study, experiences for males in nursing are complex, spanning from the privilege of being on the 'glass escalator' to the stigmatization for being in nursing. Although this is so, recruiting more males into the APN workforce may address the general shortfall in the profession. Addressing this shortfall may inevitably improve nurses' working conditions (Clifton et al., 2020).
Lastly, within the context of this study, nurses have expressed apprehension on becoming APNs because of the lack of role clarity (Woo et al., 2019(Woo et al., , 2020. Hence, a delineation of the APN role may facilitate the recruitment of APNs. More specifically, to reduce the stigmatization and encourage gender diversity in the workforce, it may be propitious to have positive male role models mentor nurses (Armitage, 2013). This has also been demonstrated in this study.
Intentional mentoring of male nurses through a 'buddy' system and informal meetings may be good avenues for men to share experiences, which can help reduce feelings of isolation and exclusion. Additionally, nursing leaders and administrators should be more proactive in creating a positive and inclusive environment where male nurses are supported and accepted by patients and peers and improve their visibility (Younas et al., 2022). Such strategies are envisioned to retain males sufficiently long in nursing to pursue the APN career.

| Limitations
One limitation of this study was the purposive sampling of the participants, which was distinctive of qualitative inquiry. Though they were in various APN career stages, the participants were all recruited from Singapore, which may limit the generalizability of the findings to other countries. Nonetheless, the aim of this study was not to generalize but to promote the transferability of knowledge from one context to another. Our findings provide pioneering insights that can be transferred to other contexts in similar stages of APN development.

| CONCLUSIONS
Although males in nursing enjoy opportunistic advantages in entering the APN workforce, they are not interested in the role and not staying long enough in the nursing profession to become APNs. This paper offers insights into the poor recruitment of males in the APN workforce and suggestions to combat that. Further inquiry is required to understand how regulatory bodies and nursing institutions may promote a more inclusive environment that reduce gender stigmatization.

| Implications for nursing management
Nurse managers should be more cognizant of the different social stereotypes faced by males and females in nursing. With such awareness, they can be more supportive and less biased in career counselling and job appraisals. In light of the need to improve APN recruitment, institutional leaders and policy makers need to be more proactive in recruiting RNs into the APN preparatory training. Greater flexibility in the completion of the training for female candidates with children may be advantageous to increasing interest in the APN career. Positive role modelling and clear articulation of the APN role may also improve the recruitment of both male and female candidates into the APN workforce.